Composite prescription form

ABSTRACT

A composite prescription form comprising five individual form parts which are detachably secured together at their upper ends in a superposed relationship with respect to each other. The prescription form contains a plurality of preprinted information and the pharmacist types the form upon receiving a new prescription. The form is then separated with one portion of the first or top part being used as a prescription label and the other portion of the first part being filed for daily computation and record. The second part of the form is a sack label with the third part of the form being the prescription itself. The fourth part of the form is identical to the third part and provides a copy of the original prescription. The fifth part of the form is a three-line part which is separable from the form so that it may be secured to a permanent patient prescription ledger card. A modification of the form is also disclosed and is designed for use as a refill prescription form. The modification utilizes three parts which are substantially identical to parts 1, 2 and 5 of the first described forms, respectively.

United States Patent [72] Inventor William A. Burke 1812 N. Clebum, Grand Island, Nebr. 68801 [21] Appl. No. 826,066 [22] Filed May 9,1969 [45] Patented Dec. 7, I971 [54] COMPOSITE PRESCRIPTION FORM 6 Claims, 7 Drawing Figs.

[52] [1.8. CI 282/23, 282/9 R. 283/2l [5|] Int. Cl B411 H24 [50] Field of Search 282/23, 8 R,9R, 22 R, 22 A; 283/l8,2l, I9

[56] References Cited UNITED STATES PATENTS 2,576,164 ll/l95l Willis 282/23 730,083 6/l903 Beach... 283/2l X 1,203,902 lI/l9l6 Nichols 282/23 2,092,127 9/1937 Lankton... 282/23 3,222,086 l2/I965 Gosselin 282/23 R FOREIGN PATENTS 1,176,986 8/1964 Germany 283/23 M Na. CLEBURN an: m; hl'lnlkli GRAND tsunami.

France Germany ABSTRACT: A composite prescription form comprising five individual form parts which are detachably secured together at their upper ends in a superposed relationship with respect to each other. The prescription form contains a plurality of preprinted information and the pharmacist types the form upon receiving a new prescription. The form is then separated with one portion of the first or top part being used as a prescription label and the other portion of the first part being filed for daily computation and record. The second part of the form is a sack label with the third part of the form being the prescription itself. The fourth part of the form is identical to the third part and provides a copy of the original prescription. The fifth part of the form is a three-line part which is separable from the form so that it may be secured to a permanent patient prescription ledger card. A modification of the form is also disclosed and is designed for use as a refill prescription form. The modification utilizes three parts which are substantially identical to parts I, 2 and 5 of the first described forms. respectively.

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T I I 96) DR. PM n no! REED Anouss COMPOSITE PRESCRIPTION FORM Current prescription filling practice is such that it takes approximately 7 minutes for the pharmacist to type the prescription and copy thereof, prescription label, sack label, patient record and store record. Obviously, any reduction of this 7 minute period would be highly economically desirable.

Therefore, it is a principal object of this invention to provide a composite prescription form.

A further object of this invention is to provide a composite prescription form which includes five individual parts which are detachably secured together in a superposed relationship.

A further object of this invention is to provide a composite prescription form for use with new prescriptions.

A further object of this invention is to provide a composite prescription form for use with refill prescriptions.

A further object of this invention is to provide a composite prescription form which substantially reduces the time needed for typing various forms connected therewith.

A further object of this invention is to provide a composite prescription form including a three-line part which is designed for use with a permanent patient prescription ledger card.

A further object of this invention is to provide a composite prescription form wherein information is transferred from one part of the form to another to eliminate the necessity of individually typing the same.

A further object of this invention is to provide a composite prescription form which is convenient to use.

A further object of this invention is to provide a composite prescription form which provides a convenient and accurate record.

A further object of this invention is to provide a composite prescription form which is economical of manufacture, and refined in appearance.

These and other objects will be apparent to those skilled in the art.

This invention consists in the construction, arrangements, and combination of the various parts of the device, whereby the objects contemplated are attained as hereinafter more fully set forth, specifically pointed out in the claims, and illustrated in the accompanying drawings in which:

FIG. I is a top view of the form;

FIG. 2 is an exploded top view of the form illustrating the individual portions of the form;

FIG. 3 is a sectional view as seen along lines 33 of FIG. 1;

FIG. 4 is a top view of a modification of the form;

FIG. 5 is an exploded top view of the form of FIG. 4;

FIG. 6 is a sectional view as seen along line 6-6 of FIG. 4; and

FIG. 7 is a fragmentary view of a ledger card adapted to have the fifth part of the first form or the third part of the second form detachably secured thereto for a permanent patient record.

The composite prescription form of FIGS. 1-3 is generally designated by the reference numeral 10 and includes parts 12, 14, l6, l8 and and may be constructed of paper generally described as of the pressure sensitive type so that information will be transferred between the various parts of the form but it is preferred that the forms be constructed of conventional paper which would require that carbons 22, 24, 26 and 28 be employed.

The parts and carbons are assembled in a superposed relationship and are secured at their upper ends by any convenient means such as adhesive or the like and such relationship is best illustrated in FIG. 3.

Part 12 is provided with a perforated tear line 30 which separates the top area 32 from the bottom area 34 thereof. Bottom area 34 has a perforated tear line 36 provided therein which separates or divides it into portions 38 and 40. Bottom area 34 has a preprinted top line 42 which is divided into areas entitled, DATE, RX NUMBERS, PATIENT, AMT, IN- GREDIENT, indicated by the reference numerals 44, 46, 48, 50 and 52 respectively. Bottom area 34 is provided with a second line 54 positioned below line 42 which is divided into areas 56, 58, 60, 62 and 64 positioned below areas 44, 46, 48, 50 and 52 respectively. Area 58 is preprinted with a prescription number which happens to be 124658 in this case for purposes of illustration. Bottom area 34 is also provided with a third line 66 which is divided into areas entitled, DR., REFIL- LABLE and ADDRESS, which are indicated by the reference numerals 68, 70 and 72 respectively.

Bottom area 34 is also provided with an area 74 wherein the doctor's directions would be typed by the pharmacist and an area 76 for the pharmacy label identifying the drugstore with pertinent information. Area 74 would be larger than that in dicated in the drawings while the pharmacy label would be slightly smaller than that indicated in the drawings. It is desired that area 74 be large enough for at least four lines of typing. Portion 40 of bottom area 34 is provided with a subarea 78 entitled DRUG CODE No. (which is the drug identicode IBM number) and a subarea 80 wherein the following preprinted statement is found, Thank you. Save this for taxes and insurance." The letter N is also found in subarea 80 as well as line 82 which is followed by the letters R. P. Immediately above line 82 is the phrase Rx filled by. Portion 40 is provided with a spindle perforation 84 formed therein. Portion 34 serves as the prescription label while portion 40 serves as a daily record for the drugstore. Portion 40 permits the pharmacist to place the same on a spindle so that the daily business for one day can be recorded by adding up the dollar and cents amount of new prescriptions and counting them for numerical tally. It is preferred that part 12 be gum backed or have some other suitable adhesive applied to the back thereof to facilitate the attachment of portion 38 to the prescription.

Carbon 22 is positioned between parts 12 and I4 and is designed to transfer information therethrough. Part 14 serves as a sack label for the actual prescription once it has been placed in the customer's sack. It contains all the pertinent information of part 12 with the exception that the ingredients area 64 is blocked out. Area 64' corresponds to and is positioned beneath area 64 of part 12. It is customary practice to not informthe customer of the ingredients in the prescription and that is the reason that area 64' is blocked out.

Carbon 24 is positioned beneath part 14 and above part 16 as illustrated in the drawings. Part 16 is the prescription itself and contains all the information of part 12 besides having an area 86 for the actual refill directions of the doctor, the doctor's name and address and his registry number. Part 16 is also provided with an area 88 wherein the actual prescription is typed or written in full detail.

Carbon 26 is positioned beneath part 16 and above part 18 as illustrated in FIG. 3. Part 18 is identical to part 16 so that it is available in the instance wherein the pharmacy requires a copy of the original prescription such as: A copy for filing in cases of narcotics, abuse drugs, or possible for a telephone copy prescription to mail back to the doctor. Parts 16 and 18 are provided with perforations 73, 75 and 77, 79 respectively to facilitate their positioning in the prescription file.

Carbon 28. is positioned beneath part [8 and above part 20 as illustrated in FIG. 3. Part 20 is provided with lines 42', 54, and 66' which correspond with lines 42, 54 and 66 of part 12 respectively. Part 20 is comprised of Davac paper or other suitable paper of the label type having an adhesive or the like on the back side thereof so that it may be removed from the form 10 and conveniently secured to a patient prescription ledger card generally referred to by the reference numeral 90 in FIG. 7. The patient prescription ledger card 90 is set up with the patient's name and address, his doctors, the children and wife's name and the allergies of anyone in the family that the pharmacist should be concerned with. Part 20 is stuck onto the ledger card 90 in vertical order as the patient has the prescription filled. The ledger card is maintained in the pharmacists files for purposes of:

1. Being able to find the prescription number if the patient loses the prescription;

2. For reference by the patients doctor;

3. For insurance purposes for the patient;

4. For income tax purposes for the patient;

5. For control for drug abuse drugs; and

6. For control of allergies to medication for the patient. Card 90 may be photocopied at the end of the calendar year and a copy given to the patient for his income tax and insurance purposes. it may also be photocopied any time during the year necessary to fill these demands.

Carbons 22, 24, 26 and 28 are preferably provided with perforated tear lines 92, 94, 96 and 98 respectively for convenience in removing the same from the form 10. Parts 12, 14, 16, 18 and 20 are provided with perforated tear lines 30, 93, 95, 97 and 99 respectively for convenience in removing the same from the form 10.

FIGS. 4-6 illustrate a modification of the form and is referred to by the reference numeral 100. Form 100 is a three part form comprised of parts 102, 104 and 106 and carbons 108 and 110. Form 100 is a refill prescription form and is substantially identical to form to the extent that parts 102, 104 and 106 correspond to parts 12, 14 and of form 10 respectively. The only difference on this form is the omission of parts corresponding to parts 16 and 18 and in the omission of a preprinted prescription number. The remaining difference is that form 100 does not have the letter N" which denotes new prescriptions such as in part 12 of form 10.

Upon receiving a new prescription, the pharmacist would place a form 10 in a typewriter and type the following information:

Date in area 54;

Patients name in area 60;

Cost of the prescription in area 62;

A one line abbreviation of the ingredients of the prescription in area 64;

Doctors name in area 68;

lndicate whether the prescription is refillable in area 70;

and

Address of patient in area 72.

The pharmacist would then type the prescription instructions in area 74 and would indicate the proper national drug code lBM number in area 78. The pharmacist filling the prescription would then type or write his initials in area 82 and would type or write the actual prescription in full detail in area 88. The refill directions would be indicated in area 86 and the doctor's name, address and registry number would be also filled in.

When the fonn 10 has been completed in the manner indicated above, portion 34 would be torn from the form 10 and portions 38 and 40 separated by means of the perforated tear line 36. Portion 38 would be secured or attached to the prescription itself since portion 38 has the prescription instructions and pharmacy label thereon. Portion 40 would be placed on a spindle or the like to provide a convenient means for the pharmacy to check the daily business. Carbon 22 may also be removed from the form 10 at this time if it is convenient to do so. Part 14 would then be torn from the form 10 along the perforated tear line 93 and would be used as a sack label once the prescription has been placed in the customer's sack. The sack label contains all of the pertinent information thereon since the typing of the same on part 12 would be reproduced thereon due to the carbon 22 being positioned therebetween. Carbon 24 may then be removed from the form 10 if it is convenient or desirable to do so. Part 16 would be torn from the form 10 along the perforated tear line 95 and is the prescription itself. Part 16 contains all of the previous information besides having the actual refill directions of the doctor, the doctor's name, address and registry number and also having a space to write or type the actual prescription in full detail. Part 16 would then be placed in the proper pharmacy file, Part 18 would also be removed from the form 10 and would be properly filed if it is necessary to maintain a duplicate copy for filing in cases of narcotics or drug abuse drugs. The pharmacist may also wish to mail part 18 to the doctor if the prescription was conveyed to the pharmacy by way of telephone. Part 20 is then torn from the form 10 along the perforated tear line 99 and is placed on the prescription ledger card as indicated previously. Thus it can be seen that a composite prescription form has been provided wherein the pharmacist need only type the information once and result in providing a prescription label, daily record, sack label, actual prescription, duplicate copy of the prescription and a part which is secured to the patients prescription ledger card. It has been found that the use of the form 10 results in a savings of approximately 3 minutes per prescription which results in approximately2 5 cents labor costs being saved per prescription. Form 10 also provides a convenient and accurate system of maintaining the proper pharmacy records with a minimum of time.

Form 100 is used in an identical manner to form 10 and is designed for use when the prescription is a refill prescription. Part 102 serves as the prescription label and business record stub as does part 12 of the form 10. Part 104 serves as the sack label as does part 14 of form 10. Part 106 serves the same purpose as the part 20 of form 10. The only difference in the preparation of form 100 with respect to form 10 is that the prescription number must be written on part 102 and the fact that parts comparable to parts 16 and 18 have been omitted since the prescription is a refill prescription.

In summary, form 10 permits the accomplishment of several basic procedures in a single operation. The form serves as a label; a record for the store of the dollar amount and the numerical amount of new prescriptions; it provides a label for a delivery sack or pickup sack; it provides the original prescription; it provides a copy of the original prescriptions; and it provides the record form in the form of a stick-on piece attached to a permanent ledger card to maintain a patients record system. All of the above steps are accomplished in one operation thereby saving many valuable minutes of the pharmacists time. Form 100 provides all of the above features with the exception of the original prescription and copy thereof. While the foregoing has described that the parts 12, 14, 16, 18 and 20 are individually torn from the form 10, it is also convenient to simultaneously tear the parts 12, 14, 16 18 and 20 from the form 10.

Thus it can be seen that the forms accomplish at least all of their stated objectives.

Some changes may be made in the construction and arrangement of my Composite Prescription Form without departing from the real spirit and purpose of my invention, and it is my intention to cover by my claims, any modified forms of structure or use of mechanical equivalents which may be reasonably included within their scope.

lclaim:

l. A composite prescription form, comprising,

at least a prescription label, a package label and a ledger card label detachably secured together in a superimposed relationship,

and a transfer means for transferring impressions from one label to other of the labels positioned therebeneath,

said prescription label having a perforated tear line provided thereon for facilitating the separation of said prescription label into first and second portions, said second portion being a record stub having a spindle per foration formed therein,

said transfer means having a nontransfer area provided thereon so that the prescription ingredients will not be indicated on said package label but will be indicated on said second portion and on said ledger card label,

a prescription sheet member removably positioned between two of the aforementioned labels,

and an auxiliary prescription sheet member removably positioned beneath said prescription sheet member,

said prescription label and said package label being substantially identical in size, said prescription sheet members having a substantially greater length than said prescription label and said package label.

2. A composite prescription form, comprising,

at least a prescription label, a package label, a ledger card label and a prescription sheet member detachably secured together in a superimposed relationship,

a transfer means for transferring impressions between the aforementioned labels and sheet member,

said prescription label and said package label being substantially identical in size,

said prescription sheet member having a substantially greater length than said labels so that certain prescription information may be imprinted on said prescription sheet member without imprinting said certain prescription information on said labels.

3. The form of claim 2 wherein said ledger card label has a substantially shorter length than said prescription label and said package label so that certain prescription information imprinted on said prescription label and said package label will not be imprinted on said ledger card label.

4. A composite prescription form, comprising,

at least a prescription label, a package label, and a ledger card label detachably secured together in a superimposed relationship,

and a transfer means for transferring impressions from one label to other of the labels positioned therebeneath,

said prescription label having a perforated tear line provided thereon for facilitating the separation of said prescription label into first and second portions, said second portion being a record stub having a spindle perforation formed therein,

said transfer means having a nontransfer area provided thereon so that the prescription ingredients will not be indicated on said package label but will be indicated on said second portion and on said ledger card label.

5. The form of claim 4 wherein a prescription sheet member is removably positioned between two of the aforementioned labels.

6. The form of claim 5 wherein an auxiliary prescription sheet member is removably positioned beneath said prescription sheet member. 

1. A composite prescription form, comprising, at least a prescription label, a package label and a ledger card label detachably secured together in a superimposed relationship, and a transfer means for transferring impressions from one label to other of the labels positioned therebeneath, said prescription label having a perforated tear line provided thereon for facilitating the separation of said prescription label into first and second portions, said second portion being a record stub having a spindle perforation formed therein, said transfer means having a nontransfer area provided thereon so that the prescription ingredients will not be indicated on said package label but will be indicated on said second portion and on said ledger card label, a prescription sheet member removably positioned between two of the aforementioned labels, and an auxiliary prescription sheet member removably positioned beneath said prescription sheet member, said prescription label and said package label being substantially identical in size, said prescription sheet members having a substantially greater length than said prescription label and said package label.
 2. A composite prescription form, comprising, at least a prescription label, a package label, a ledger card label and a prescription sheet member detachably secured together in a superimposed relationship, a transfer means for transferring impressions between the aforementioned labels and sheet member, said prescription label and said package label being substantially identical in size, said prescription sheet member having a substantially greater length than said labels so that certain prescription information may be imprinted on said prescription sheet member without imprinting said certain prescription information on said labels.
 3. The form of claim 2 wherein said ledger card label has a substantially shorter length than said prescription label and said package label so that certain prescription information imprinted on said prescription label and said package label will not be imprinted on said ledger card label.
 4. A composite prescription form, comprising, at least a prescription label, a package label, and a ledger card label detachably secured together in a superimposed relationship, and a transfer means for transferring impressions from one label to other of the labels positioned therebeneath, said prescription label having a perforated tear line provided thereon for facilitating the separation of said prescription label into first and second portions, said second portion being a record stub having a spindle perforation formed therein, said transfer means having a nontransfer area provided thereon so that the prescription ingredients will not be indicated on said package label but will be indicated on said second portion and on said ledger card label.
 5. The form of claim 4 wherein a prescription sheet member is removably positioned between two of the aforementioned labels.
 6. The Form of claim 5 wherein an auxiliary prescription sheet member is removably positioned beneath said prescription sheet member. 